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Is Urethral Pain Syndrome Really Part of Bladder Pain Syndrome?

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Is Urethral Pain Syndrome Really Part of Bladder Pain Syndrome? ISSN 2465-8243(Print) / ISSN: 2465-8510(Online) https://doi.org/10.14777/uti.2017.12.1.22 Review Urogenit Tract Infect 2017;12(1):22-27 http://crossmark.crossref.org/dialog/?doi=10.14777/uti.2017.12.1.&domain=pdf&date_stamp=2017-04-25 Is Urethral Pain Syndrome Really Part of Bladder Pain Syndrome? Sung Tae Cho Department of Urology, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea Urethral pain syndrome is a symptom complex that includes dysuria, urinary Received: 24 March, 2017 urgency, frequency, nocturia, and persistent or intermittent urethral and/or pelvic Revised: 10 April, 2017 Accepted: 10 April, 2017 pain in the absence of proven infection. Bladder pain syndrome is a clinical diagnosis, based primarily on chronic symptoms of pain from the bladder and/or pelvis associated with urinary urgency or frequency in the absence of identified cause for the symptoms. To date, the term, urethral pain syndrome, remains to be unclear in referring to a distinct subgroup of bladder pain syndrome. However, these two syndromes share many similarities, except the organ of pain. This review is intended to summarize the current state of literature with regard to similar pathophysiology and possible interrelations between urethral pain syndrome and bladder pain syndrome. Keywords: Cystitis, interstitial; Urinary bladder; Urethra Correspondence to: Sung Tae Cho http://orcid.org/0000-0002-4691-6159 Department of Urology, Hallym University Kangnam Copyright 2017, Korean Association of Urogenital Tract Infection and Inflammation. All rights reserved. Sacred Heart Hospital, Hallym University College of This is an open access article distributed under the terms of the Creative Commons Attribution Medicine, 1 Singil-ro, Yeongdeungpo-gu, Seoul 07441, Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits Korea unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is Tel: +82-2-829-5198, Fax: +82-2-846-5198 properly cited. E-mail: [email protected] INTRODUCTION chronic pelvic pain [4]. Urethral pain syndrome and BPS have a lot in common, The term “urethral syndrome” was used in 1965 by except the organ of pain. To aid in understanding the Gallagher et al. [1]. In 2002, the term “urethral pain syndrome” possible relationship between these two syndromes, we was implemented by the International Continence Society summarized both syndromes and presented evidence-based (ICS) to delineate the occurrence of recurrent episodic information on whether additional similarities with regard urethral pain, usually on voiding, with daytime frequency to pathophysiology exist between these two syndromes. and nocturia, in the absence of proven infection. It is often common for dyspareunia to also be described. Regardless URETHRAL PAIN SYNDROME of the symptoms, the lack of evidence of urinary tract infection or other obvious pathologies is essential [2]. Due Urethral pain syndrome is a symptom complex that to these nonspecific symptoms, there are often overlaps includes dysuria, urinary urgency, frequency, nocturia, and with disease pictures, such as interstitial cystitis/bladder persistent or intermittent urethral and/or pelvic pain in the pain syndrome (IC/BPS) or the overactive bladder (OAB). absence of proven infection [2]. The diagnosis implies a As such, some authors describe the urethral syndrome as specific duration of symptoms, a minimum of six months an early form of IC [3]. In the current guidelines of the [5]. The exact etiology is unknown; however, infectious European Association of Urology (EAU), urethral pain and psychogenic factors, urethral spasms, early IC, hypoe- syndrome is considered to be a part of the complex of strogenism, squamous metaplasia, as well as gynecological 22 Sung Tae Cho. Urethral Pain Syndrome of BPS 23 risk factors are discussed [6]. There is now evidence that ulcer. For several years, this finding was the hallmark of the microscopic paraurethral glands connected to the distal IC, and urologists would look for ulcers but failed to make third of the urethra in the prevaginal space are homologous the diagnosis in their absence [13]. to the prostate. They stain histologically for prostate-specific The Interstitial Cystitis Association (ICA), established in antigen and, like the prostate, are subject to infection and 1984, succeeded in gaining the National Institute of Diabetes cancer. Some researchers have theorized that inflammation and Digestive and Kidney Diseases (NIDDK)’s interest in of the female prostate (Skene glands and the paraurethral glands) the research for this field [15]. In an effort to define IC, may explain the causes of urethral pain syndrome [7]. the NIDDK held a workshop in August 1987, at which point The diagnosis is mainly based on symptoms. However, in time, the consensus diagnostic criteria were established it is important to rule out other conditions, including for the diagnosis of IC [16]. After the pilot studies to test paraurethral pathology, bladder cancer, atrophic urethral for the criteria, they were revised at the follow-up NIDDK changes, and vaginitis [5]. The incidence and prevalence workshop in 1988 [15,16]. These criteria were specifically of this condition is not well known thus far due to the designed for the basic and clinical research purposes, but lack of consensus in the method of diagnoses. In several not as a diagnostic tool for the clinician (Table 1) [17]. studies, 15-30% of women who presented with lower urinary tract symptoms (LUTS) were diagnosed with urethral pain PAINFUL BLADDER SYNDROME syndrome [8,9]. Most of these patients are women aged 20 to 30 years and 50 to 60 years. Contrary to the earlier The ICS has been standardizing the terminology of lower definition, urethral pain syndrome may also occur in men, urinary tract diseases. In 2002, for the first time, the ICS but less frequently [6,10]. This condition is more common defined IC, calling it a painful bladder syndrome (PBS), in Caucasians than other races [5]. As a result of these delineating it as: “the complaint of suprapubic pain related nonspecific symptoms, patients with urethral pain syndrome to bladder filling, accompanied by other symptoms, such often enter into urological care after long-term suffering as increased daytime and night-time frequency, in the and repeated treatment [6,11]. absence of proven urinary infection or other obvious pathology [18,19].” The ICS reserves the diagnosis of IC INTERSTITIAL CYSTITIS as a “specific diagnosis that requires confirmation by typical cystoscopic and histological features.” This definition may The first known modern documentation of a condition miss 36% of patients, primarily because it confines the pain resembling IC appeared in the early 19th century. Philip to a suprapubic location and mandates a relationship of Syng Physick described an inflammatory condition of the pain to bladder filling [18]. This disorder, despite confusion, bladder with an “ulcer” producing the same symptoms as came to be known as PBS/IC or IC/PBS. a bladder stone in 1808 [12]. He expanded this concept to include chronic frequency, urgency, and pain syndrome, BLADDER PAIN SYNDROME occurring in the absence of demonstrable etiology, which was called the ‘tic douloureux of the bladder’ in 1836 [12,13]. The European Society for the Study of Interstitial Cystitis This may represent the first description of IC. Fifty years (ESSIC) proposed a new definition and another name change later, Skene used the term IC to describe an inflammation from IC/PBS to BPS alone. The ESSIC paper, published that had “destroyed the mucous membrane partly or wholly in 2008, proposed the following definition: “Chronic (six and extended to the muscular parietes” in 1887 [14]. months or more) pelvic pain, pressure or discomfort However, because of the distinctive clinical characterization perceived to be related to the urinary bladder accompanied of the syndrome, the physician who is always remembered by at least one other urinary symptom like persistent urge and quoted is Guy Hunner [13]. Early in the 20th century, to void or urinary frequency. Confusable diseases as the he described a symptom complex of bladder pain associated cause of the symptoms must be excluded [20].” with distinguishing cystoscopic feature of mucosal lesions ESSIC also introduced a new classification system of BPS as the “elusive ulcer,” which was later termed Hunner’s types and a list of confusable diseases. BPS is indicated Urogenit Tract Infect Vol. 12, No. 1, April 2017 24 Sung Tae Cho. Urethral Pain Syndrome of BPS Table 1. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) revised the criteria for interstitial cystitis in 1988 To be included as IC, patients must have either glomerulations on cystoscopic examination or a classic Hunner’s ulcer, and they must have either pain associated with the bladder or urinary urgency. Examination for glomerulations should occur after distension of the bladder under anesthesia to 80-100 cmH2O for 1-2 min. The bladder may be distended up to two times before evaluation. The glomerulations must be diffuse–present in at least 3 quadrants of the bladder –and there must be at least 10 glomerulations per quadrant. The glomerulations must not be along the path of the cystoscope (to eliminate artifact from contact instrumentation). The presence of any one of the following will exclude the diagnosis of interstitial cystitis: 1. Bladder capacity of greater than 350 ml on awake cystometry using either a gas or liquid filling medium 2. Absence of an intense urge to void with the bladder filled to 100 ml of gas or 150 ml of water during cystometry, using a fill rate of 30-100 ml/min 3. The demonstration of phasic involuntary bladder contractions on cystometry using the fill rate described above 4. Duration of symptoms less than 9 months 5. Absence of nocturia 6. Symptoms relieved by antimicrobials, urinary antiseptics, anticholinergics, or antispasmodics 7. A frequency of urination while awake of less than eight times per day 8.
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